Rapid Programs For testosterone therapy Around The Usa

A Harvard expert shares his thoughts on testosterone-replacement therapy

It could be said that testosterone is the thing that makes guys, men. It gives them their characteristic deep voices, large muscles, and body and facial hair, differentiating them from girls. It stimulates the growth of the genitals , plays a role in sperm production, fuels libido, and contributes to regular erections. Additionally, it fosters the creation of red blood cells, boosts mood, and assists cognition.

Over time, the "machinery" which produces testosterone gradually becomes less powerful, and testosterone levels begin to fall, by approximately 1 percent a year, starting in the 40s. As men get into their 50s, 60s, and beyond, they might start to have signs and symptoms of low testosterone like reduced sex drive and sense of energy, erectile dysfunction, decreased energy, reduced muscle mass and bone density, and nausea. Taken together, these signs and symptoms are often called hypogonadism ("hypo" significance low working and"gonadism" referring to the testicles). Researchers estimate that the condition affects anywhere from two to six million men in the USA. Yet it's an underdiagnosed problem, with just about 5% of these affected undergoing therapy.

But little consensus exists about what constitutes low testosterone, when testosterone supplementation makes sense, or what risks patients face.

Dr. Abraham Morgentaler, an associate professor of surgery at Harvard Medical School and the director of Men's Health Boston, specializes in treating prostate diseases and male sexual and reproductive difficulties. He's developed particular experience in treating low testosterone levels. In this interview, Dr. Morgentaler shares his perspectives on current controversies, the treatment strategies he utilizes his own patients, and he thinks experts should reconsider the potential connection between testosterone-replacement therapy and prostate cancer.

Symptoms and diagnosis

What symptoms and signs of low testosterone prompt the typical person to see a physician?

As a urologist, I tend to see guys because they have sexual complaints. The primary hallmark of reduced testosterone is reduced sexual desire or libido, but another may be erectile dysfunction, and any man who complains of erectile dysfunction must get his testosterone level checked. Men may experience different symptoms, like more difficulty achieving an orgasm, less-intense climaxes, a much smaller amount of fluid out of ejaculation, and a feeling of numbness in the penis when they see or experience something which would usually be arousing.

The more of these symptoms there are, the more probable it is that a man has low testosterone. Many physicians often dismiss these"soft symptoms" as a normal part of aging, however, they're often treatable and reversible by normalizing testosterone levels.

Aren't those the very same symptoms that guys have when they're treated for benign prostatic hyperplasia, or BPH?

Not exactly. There are quite a few medications that may lessen sex drive, such as the BPH drugs finasteride (Proscar) and dutasteride (Avodart). Those drugs can also reduce the quantity of the ejaculatory fluid, no wonder. But a reduction in orgasm intensity usually does not go together with therapy for BPH. Erectile dysfunction does not ordinarily go along with it either, though certainly if somebody has less sex drive or less interest, it's more of a struggle to have a fantastic erection.

How can you determine whether a man is a candidate for testosterone-replacement therapy?

There are two ways we determine whether someone has low testosterone. One is a blood test and the other is by characteristic symptoms and signs, and the correlation between those two methods is far from perfect. Generally men with the lowest testosterone have the most symptoms and guys with maximum testosterone possess the least. However, there are a number of guys who have reduced levels of testosterone in their blood and have no signs.

Looking at the biochemical numbers, The Endocrine Society* considers low testosterone to be a total testosterone level of less than 300 ng/dl, and I think that's a reasonable guide. But no one quite agrees on a number. It's similar to diabetes, in which if your fasting sugar is over a certain level, they will say,"Okay, you've got it." With testosterone, that break point isn't quite as apparent.

*Notice: The Endocrine Society recommends clinical practice guidelines with recommendations for who should and should not receive testosterone treatment. For a look at this now complete check out this site copy of these instructions, log on to www.endo-society.org.

Is total testosterone the right thing to be measuring? Or should we be measuring something else?

Well, this is another area of confusion and good discussion, but I do not think that it's as confusing as it is apparently in the literature. When most doctors learned about testosterone in medical school, they learned about total testosterone, or all of the testosterone in the human body. However, about half of their testosterone that's circulating in the bloodstream is not available to cells.

The available part of total testosterone is known as free testosterone, and it is readily available to cells. Though it's just a small fraction of the overall, the free testosterone level is a fairly good indicator of reduced testosterone. It's not perfect, but the correlation is greater compared to testosterone.

Endocrine Society recommendations summarized

This professional organization recommends testosterone treatment for men who have

Therapy Isn't Suggested for men who've

  • Prostate or breast cancer
  • a nodule on the prostate that can be felt during a DRE
  • that a PSA higher than 3 ng/ml without further evaluation
  • a hematocrit greater than 50 percent or thick, viscous blood
  • untreated obstructive sleep apnea
  • severe lower urinary tract infections
  • class III or IV heart failure.

    Do time of day, diet, or other elements influence testosterone levels?

    For years, the recommendation was to get a testosterone value early in the morning because levels begin to drop after 10 or even 11 a.m.. However, the data behind this recommendation were drawn from healthy young men. Two recent studies showed little change in blood glucose levels in men 40 and older within the course of the day. One reported no change in typical testosterone till after 2 p.m. Between 6 and 2 p.m., it went down by 13%, a small amount, and probably not enough to affect diagnosis. Most guidelines nevertheless say it's important to perform the test in the morning, but for men 40 and over, it probably does not matter much, as long as they obtain their blood drawn before 5 or 6 p.m.

    There are a number of very interesting findings about dietary supplements. For instance, it seems that individuals that have a diet low in protein have lower testosterone levels than men who eat more protein. But diet hasn't been researched thoroughly enough to make any clear recommendations.

    Exogenous vs. endogenous testosterone

    Within the following article, testosterone-replacement treatment refers to the treatment of hypogonadism with exogenous testosterone -- testosterone that is produced outside the body. Depending upon the formulation, treatment can lead to skin irritation, breast tenderness and enlargement, sleep apnea, acne, reduced sperm count, increased red blood cell count, along with other side effects.

    Preliminary studies have shown that clomiphene citrate (Clomid), a drug generally prescribed to stimulate ovulation in women struggling with infertility, can boost the production of natural testosterone, also termed nitric oxide, in men. Within four to six weeks, each one the guys had heightened levels of testosteronenone reported some side effects throughout the year they had been followed.

    Since clomiphene citrate is not accepted by the FDA for use in males, little information exists about the long-term ramifications of taking it (such as the probability of developing prostate cancer) or whether it's more effective at boosting testosterone compared to exogenous formulas. But unlike exogenous testosterone, clomiphene citrate preserves -- and potentially enriches -- sperm production. That makes drugs such as clomiphene citrate one of just a few choices for men with low testosterone who wish to father children.

    What kinds of testosterone-replacement therapy are available? *

    The earliest form is the injection, which we still use because it's cheap and since we reliably get fantastic testosterone levels in almost everybody. The drawback is that a man needs to come in every couple of weeks to find a shot. A roller-coaster effect can also occur as blood glucose levels peak and return to baseline. [Watch"Exogenous vs. endogenous testosterone," above.]

    Topical therapies help maintain a more uniform level of blood testosterone. The first kind of topical treatment has been a patch, but it has a quite high rate of skin irritation. In one study, as many as 40% of men who used the patch developed a red area in their skin. That restricts its usage.

    The most widely used testosterone preparation from the United States -- and also the one I begin almost everyone off -- is a topical gel. There are just two brands: AndroGel and Testim. According to my experience, it tends to be absorbed to good levels in about 80% to 85% of men, but leaves a significant number who do not consume sufficient for this to have a favorable impact. [For details on several different formulations, see table ]

    Are there any drawbacks to using gels? How long does it take for them to work?

    Men who start using the implants need to return in to have their own testosterone levels measured again to be certain they are absorbing the proper amount. Our target is the mid to upper range of normal, which usually means around 500 to 600 ng/dl. The concentration of testosterone in blood actually goes up quite quickly, within a few doses. I normally measure it after 2 weeks, even although symptoms may not alter for a month or two.

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